Temp Family Grant | Spierings Cancer Foundation

Company

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Section 1: Eligibility

This section helps us confirm basic program eligibility before you continue.

Are you currently receiving cancer treatment, or have you received cancer treatment within the past 12 months?*

(Cancer treatment may include chemotherapy, radiation, surgery, immunotherapy, or hospice care.)

Yes

We’re so sorry, our Family Grant Program is available to individuals who are currently receiving, or have recently received, cancer treatment. Thank you for considering our program. You may find additional local resources here: Additional Resources.

Have you previously received a Spierings Cancer Foundation Family Grant?*

Yes

Our program is currently limited to one Family Grant per individual. Thank you for your understanding. You may find other local support resources here: Additional Resources.

Which county do you currently reside in?*

Please choose one.

Brown

Calumet

Outagamie

Winnebago

Waupaca

None of the Above

We’re sorry, our Family Grant Program is currently available to individuals residing in Brown, Calumet, Outagamie, Winnebago, or Waupaca counties. Thank you for reaching out, and please feel free to explore additional local resources here: Additional Resources.

Section 2: Applicant and Patient Information

This section helps us understand who the application is for and how to contact you.

Are you completing this application for yourself, or on behalf of someone else?*

For myself

On behalf of someone else

Your Name

First Last

Your relationship to the patient

Please complete the following to the best of your knowledge using the patient’s information.

Patient's Name*

First Last

Patient's Phone*

Patient's Email*

Patient's Address*

Street Address Address Line 2 City State ZIP Code

Section 3: Demographics & Household

This information helps us understand household size and avoid duplicate applications.

Patient's Gender*

Male

Female

Choose not to identify

Patient's Date of Birth*

Month

Day

Year

What is the patient’s preferred language for communication?*

English

Other

How many people, including yourself, currently live in your household and rely on this income?*

This helps us understand the number of individuals supported through our Family Grant Program.

Current employment status*

Section 4: Financial Snapshot

We use this information to better understand your needs and how we can help.

Approximate total monthly household income*

Please include wages, disability, Social Security, pension, or other sources.

Approximate total monthly household expenses*

For example: housing, utilities, groceries, insurance, transportation.

Are you currently covered by health insurance?*

Yes

Section 5: Medical Information

This helps us understand treatment-related expenses and care needs.

What type of cancer has the patient been diagnosed with?*

Cancer treatment center or hospital system*

Please share where the patient is being treated

Section 6: Your Story

This is your opportunity to share more of your story with us.

In 250 words or less, please share your story. We would love to learn more about you, your family, and the concerns you are facing as you move through treatment.*

Section 7: Grant Need

Our goal is to help ease one financial worry.

What is your greatest need right now?*

Our goal is to help ease one financial worry. Please share how you would use the grant funds.

Housing

Food

Medical Expenses

Transportation

Utilities

Section 7: Physician Confirmation & Consent

Upload Your Completed Physician Confirmation Form*

As part of the grant application process, we require a signed Physician Confirmation form. If you have not yet downloaded the form and had your doctor complete and sign it, please save your application now.

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Consent*

I am voluntarily providing this information to Spierings Cancer Foundation, I give my full consent to Spierings Cancer Foundation and any Spierings Cancer Foundation employees or volunteers to retain and access this information.

I agree

Before You Begin:

A Physician's Confirmation Is Required to Complete Your Application

Family Grant Application 2026

Section 1: Eligibility

Section 2: Applicant and Patient Information

Section 3: Demographics & Household

Section 4: Financial Snapshot

Section 5: Medical Information

Section 6: Your Story

Section 7: Grant Need

Section 7: Physician Confirmation & Consent

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